Author Topic: British Society for Sexual Medicine Guidelines  (Read 1175 times)

sad_dad

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British Society for Sexual Medicine Guidelines
« on: September 23, 2016, 03:08:44 PM »
Managed to get hold of a copy of the above, not sure if I can attach files here so added it to an online storage site

https://app.box.com/s/vobznqw07c4n0h4myh4kzfwh8v55xifr

James G

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Re: British Society for Sexual Medicine Guidelines
« Reply #1 on: September 24, 2016, 12:45:32 AM »
Thanks sad_dad
I don't think these are markedly different to the previous guidelines BSSM, EAU, Endocrine Society, but were brought together after "Restore The Man" series of medical meetings as a concensus statement, and a guide for doctors to follow when faced with a man with possible hypogonadism.
I think where a lot of guys will fall down is faced with the contents of table 1 - symptoms are non specific and may occur in a number of conditions, and thus  it may not be thought of by your busy GP unless flagged up as a concern by the guy. The physical findings are likely to be telling, and the robustly built gent who shaves everyday and has a full chest of hair is unlikely to get even a passing consideration of low T from the doc. even with suggestive symptoms. It takes quite a low T to produce the typical signs of low T and as we have seen it is often only those guys with REALLY lowT  ( often less than 6 nmol /L ) who actually go on and get serious consideration for TRT. I think the most telling but small box on the algorithm page relating to lifestyle modifications is key, and something men wish to ignore but your doctor won't. Adjusting lifestyle factors weight loss, change in medicines, exercise. They will want to see you changing these before giving any credence to your T result. And it is clear anything over 12 is not getting you anywhere anytime soon.
It is encouraging though that there is an acceptance that medium low 8-12 levels are still worthy of a trial.
There is often criticism here that you don't get a full spectrum of tests done at the get-go. Here it is clear the T level will be done first and ONLY if it is low enough will further investigations get done. Perhaps that will address those here who agonise they can't get the SHBG or PROLACTIN done as if that will suddenly reveal everything. This seems to suggest that these tests are not necessary (in the assessment of low T ) unless T is low. Of course testing for PRL in the assessment of a possible pituitary adenoma  is a whole different matter with a whole different set of clinical symptoms.
So, a useful guideline if it gets read of course by professionals, and also useful for expectant men to look at and understand why they are not getting what they expect from those professionals.
 I may have said before you can't blame your doctor for following guidelines and then not treat you when they continue to follow the same guidelines that don't allow them to treat you. Perhaps that aspect is more transparent now?
However I don't think it will slow the number of guys who can't accept that they don't fit the criteria or have results that are not consistent with low T from continuing to push for T treatment.
Not a criticism of course, simply an observation.
But I think with clearer and perhaps easier to assimilate guidelines - a visual algorithm rather than a wordy document, a piece of paper that can sit on the desk or pin board rather than 10 pages sitting in the guidelines file - then this condition may be thought about more by doctors and perhaps taken more seriously. But with more clarity comes more adherence to said guidelines and perhaps then doctors have more weight in saying - "look, here are the guidelines I have to follow and you fit along this path " whether that is towards T treatment or out the door to try lifestyle changes and no further consideration of the subject of low T. Perhaps time will tell. I would love for more guys to get proper consideration of their symptoms, to at least be heard in their fear that they have lowT; it would great for those who truly need treatment get it, and without a great debate about whether to or not from their doctor. But it would also be great for those guys who do not have lowT but have symptoms that are affecting their lives in profound ways are able to be moved on from the lowT bandwagon and simething else looked for to explain their symptoms. Too many men waste too much time pursuing a rainbow that will never bear gold when they should be disregarding that rainbow and seeking gold in another place. I think that is an essential role for their doctors, finding a solution for these guys that doesn't involve a never ending quest for hormones. I hope these guideline help.
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Ashto70

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Re: British Society for Sexual Medicine Guidelines
« Reply #2 on: September 24, 2016, 08:58:00 AM »
Hi gents.

Thanks so much for making us aware of this and providing the link.
After a quick read I tend to go with James that these are more a consolidation and summary of the different sets of guidelines already in existence. However, I do think this particular guideline paper is a much more digestible and straight forward read compared to similar guidelines from the Endocrine Society and Urological Society et al. Dr Geoff Hackett is also one of the writers responsible for underpinning the diagnosis and treatment for low testosterone, and that's got to be a plus-point for patients as well as doctors referring to the document.

The layout and format is also much easier on the eye, and both professionals and laymen or patients can read and understand it clearly.

The only factor that's lacking for me in this new set of guidelines, is there's no mention of an oestrogen test for either investigating causes, or in managing the condition after commencement of therapy. Sooner or later I hope doctors will understand this is a concern for patients. The USA are a decade ahead as usual in their medical attitude to hypogonadism, and they test oestrogen as a matter of course in many of their treatment facilities.

Thanks once again sad-dad. It's a good and useful find.
Craig

James G

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Re: British Society for Sexual Medicine Guidelines
« Reply #3 on: September 24, 2016, 10:48:18 AM »
Hi Craig,
call me an old cynic but I am not sure that the americans have any broader guidelines for hypogonadism than in europe - indeed i think the endocrine society is the american body responsible for guidance in america, and their stance is very much the same (-ish) as the european approach. What they do have however is a market economy for healthcare and if you add another blood test onto the panel undertaken for hypogonadism then it is ker-ching 💲💲💲 for the treating physician or clinic. I am not sure they infact do very much about E2 levels even if tested for. I am sure there are no guidelines that recommend testing for E2 and nothing at all suggesting treating any changes in E2. For better or worse of course.
All I will say from person experiences is that I have flatly been refused on a number of occasions to get an E2 test - it is waved away with a hand gesture and a 'it's completely unnecessary' response. And I have not been able to come to an underlying reason for it - is it truly unnecessary, is it because there is nothing in guidelines for it (and then for some good reason presumably; I imagine it is something that is talked about when the great and good gather round a table to devise the guidelines) and so no one will test for it, or is it they would have no idea what to do with the result if it was "abnormal". I guess if you are going looking for something and testing something out you do need to have a plan for what you do if you find a result that is not normal, and i think that answer in the medical community is not forthcoming.
My only chink in the medical armour that I have been able to glean on one occasion was a half-hearted 'James, you have no signs of having high oestrogen so the lab won't do it' and 'you will never get an excess of oestrogen when you are on therapeutic doses of gels' and that may be because you never get big swings / peaks and troughs of levels that one might with injectables. Perhaps where this arises is from the BB community where there is use of supratherpeutic doses of testosterone being administered over a long period of time, there oestrogen may well start to have an impact. But we are not in the realm of BB levels of use I think here?
I think the bottom line is that E2 testing is not going to gather any credence in the endocrine community or find a foot hold in medical guidelines any time soon, and maybe we have to accept that (for now) rather than agonising and wringing our hands about it on a daily basis. 
It is clear no one is going to do it for me despite repeated requests so I have just moved on. If they decide to test me sometime in the future when thoughts about this have caught up then fine. Until then ... there is life to lead.
PeaceThroughCulture
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JG

nick

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Re: British Society for Sexual Medicine Guidelines
« Reply #4 on: September 25, 2016, 09:15:29 AM »
Hi James,

Just on the Oestrogen testing.

Gels can convert to Oestrogen in some cases. I remember reading an article on it. A problem with the androgen receptors under the skin do it as far as I recall.

Any one of symptoms like sore nipples breast tenderness, adipose fat and elevated blood levels combined with ineffective Testosterone therapy would be triggers for a GP/normal Endo to test I'd suggest.

In truth though, if you want a holistic approach to our hormones then Dr Conway et als' Andrology clinic at UCLH in London would be the place to get referred to. It is a tertiary service so accessible from any Trust in the UK. You would be tested there I'd say.

Incidentally, this is very much a post code thing. I requested Oestradiol testing from my GP having explained why and got it no problem. Others I know have had similar results, one or two have been prescribed AIs as a result, but by far the greater number have been refused.   

Hope it helps,

Cheers,

Nick

Ashto70

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Re: British Society for Sexual Medicine Guidelines
« Reply #5 on: September 25, 2016, 12:25:11 PM »
Hi gentleman.

Yes there's definitely a money orientated approach to male health in the USA that we don't see in the UK. Many healthcare facilities in the USA have similar guidelines to our own for low testosterone. It seems to me though that "for a sum" lots of health care providers in the USA will go that bit further to strive for optimisation in treatment for hypogonadism. This often includes adequate monitoring to ensure levels of aromatisation are kept in check. Unfortunately, due to the design and intent of the NHS, we aren't the subjects of preventative medicine or optimal health, but rather reactive medicine.

High oestrogen is certainly something commonly seen in the body-building community due to - as you say - supraphysiological levels of testosterone use. Still, a proportion of us guys on therapy may be naturally predisposed or sensitive to aromatisation. For sure the therapeutic levels used in treatment for hypogonadal testosterone deficient men isn't usually enough to drift into the realms of over-aromatisation but it does occur in some. I'm thinking of naturally obese (endomorphic) stature of men, older gents, or those with additional conditions like diabetes mellitus, or Kleinfelter's Syndrome, can sometimes be susceptible to the effects of high oestrogen conversion.

I personally feel that GP's and specialist consultants should be aware of the possibility of patients suffering symptoms of high oestrogen, and they should also be aware of any particular demographic population of patient that may be sensitive to aromatisation. Following from this should be a brief overview of tests, interpretation, and treatment for those with over-aromatisation.

I've never been once offered an oestrogen test, so like yourself, don't hold out much hope of any positive changes in this direction in the near future at least. At the moment it is very much a postcode type lottery, as Nick mentions. Some doctors in a few areas are more empathetic, or even more learned in this area of medicine. Sadly though, most GPs and consultants in the country consider high oestrogen a myth or a non-risk factor to patients undergoing testosterone therapy.

Best regards.
Craig